Ethnoracial Risk Variation Across the Psychosis Continuum in the US: A Systematic Review and Meta-Analysis

Importance

Studies suggest a higher risk of schizophrenia diagnoses in Black vs White Americans, yet a systematic investigation of disparities that include other ethnoracial groups and multiple outcomes on the psychosis continuum is lacking.

Objective

To identify ethnoracial risk variation in the US across 3 psychosis continuum outcomes (ie, schizophrenia and other psychotic disorders, clinical high risk for psychosis [CHR-P], and psychotic symptoms [PSs] and psychotic experiences [PEs]).

Data Sources

PubMed, PsycINFO and Embase were searched up to December 2022.

Study Selection

Observational studies on ethnoracial differences in risk of 3 psychosis outcomes.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Using a random-effects model, estimates for ethnoracial differences in schizophrenia and PSs/PEs were pooled and moderation by sampling and setting was determined, along with the assessment of heterogeneity and risk of bias.

Main Outcomes and Measures

Risk of schizophrenia and other psychotic disorder, CHR-P, and conversion to psychosis among CHR-P and PSs/PEs.

Results

Of 64 studies in the systematic review, 47 were included in the meta-analysis comprising 54 929 people with schizophrenia and 223 097 with data on PSs/PEs. Compared with White individuals, Black individuals had increased risk of schizophrenia (pooled odds ratio [OR], 2.07; 95% CI, 1.64-2.61) and PSs/PEs (pooled standardized mean difference [SMD], 0.10; 95% CI, 0.03-0.16), Latinx individuals had higher risk of PSs/PEs (pooled SMD, 0.15; 95% CI, 0.08-0.22), and individuals classified as other ethnoracial group were at significantly higher risk of schizophrenia than White individuals (pooled OR, 1.81; 95% CI, 1.31-2.50). The results regarding CHR-P studies were mixed and inconsistent. Sensitivity analyses showed elevated odds of schizophrenia in Asian individuals in inpatient settings (pooled OR, 1.84; 95% CI, 1.19-2.84) and increased risk of PEs among Asian compared with White individuals, specifically in college samples (pooled SMD, 0.16; 95% CI, 0.02-0.29). Heterogeneity across studies was high, and there was substantial risk of bias in most studies.

Conclusions and Relevance

Findings of this systematic review and meta-analysis revealed widespread ethnoracial risk variation across multiple psychosis outcomes. In addition to diagnostic, measurement, and hospital bias, systemic influences such as structural racism should be considered as drivers of ethnoracial disparities in outcomes across the psychosis continuum in the US.

Inequality on the frontline: A multi-country study on gender differences in mental health among healthcare workers during the COVID-19 pandemic

Healthcare workers (HCWs) were at increased risk for mental health problems during the COVID-19 pandemic, with prior data suggesting women may be particularly vulnerable. Our global mental health study aimed to examine factors associated with gender differences in psychological distress and depressive symptoms among HCWs during COVID-19. Across 22 countries in South America, Europe, Asia and Africa, 32,410 HCWs participated in the COVID-19 HEalth caRe wOrkErS (HEROES) study between March 2020 and February 2021. They completed the General Health Questionnaire-12, the Patient Health Questionnaire-9 and questions about pandemic-relevant exposures. Consistently across countries, women reported elevated mental health problems compared to men. Women also reported increased COVID-19-relevant stressors, including insufficient personal protective equipment and less support from colleagues, while men reported increased contact with COVID-19 patients. At the country level, HCWs in countries with higher gender inequality reported less mental health problems. Higher COVID-19 mortality rates were associated with increased psychological distress merely among women. Our findings suggest that among HCWs, women may have been disproportionately exposed to COVID-19-relevant stressors at the individual and country level. This highlights the importance of considering gender in emergency response efforts to safeguard women's well-being and ensure healthcare system preparedness during future public health crises.

The separate and joint effects of recent interpersonal abuse and cannabis use on psychotic experiences: findings from students in higher education in the United States

BACKGROUND

Various forms of interpersonal abuse (e.g., physical, emotional, sexual) and cannabis use across the lifespan have both been known to increase odds of psychotic experiences; however, there have been few studies examining their separate and joint effects in the United States.

METHODS

We analyzed data from the Healthy Minds Study (2020-2021) and used multivariable logistic regression and interaction contrast ratios to assess separate and joint effects of interpersonal abuse (past 12 months) and cannabis use (past 30 days) on psychotic experiences (past 12 months).

RESULTS

Students who only used cannabis had significantly greater odds of psychotic experiences (aOR: 1.70; 95% CI 1.58-1.82), as well as those who only experienced interpersonal abuse (aOR: 2.40; 95% CI 2.25-2.56). However, those who reported both cannabis use and interpersonal abuse had the greatest odds, exceeding the sum of these individual effects (the combined effect aOR: 3.46; 95% CI 3.19-3.76).

CONCLUSIONS

Recent interpersonal abuse and recent cannabis use both separately and jointly increase odds of having recent psychotic experiences. Future research should continue to examine the potential interactive and additive impact of multiple known exposures to better inform primary and secondary prevention efforts.

Ethno-racial variation in psychotic experiences in the United States: Findings from the National Latino and Asian American Survey and the National Survey of American Life

BACKGROUND

Ethno-racial differences in psychosis risk are documented; however, there is less research on whether these differences extend to sub-threshold psychotic experiences, and whether there is significant variation within ethno-racial categories.

METHODS

We analyzed data from the National Latino and Asian American Survey (NLAAS) and the National Survey of American Life (NSAL). Using multivariable logistic regression, we examined the association between race/ethnicity and lifetime psychotic experiences among Latino, Asian, and Black adults in the general population, adjusting for gender, age, nativity, education level, income level, employment status, and everyday discrimination.

RESULTS

Puerto Ricans, Cubans, and other Hispanics had greater odds of lifetime psychotic experiences when compared with Mexicans, though differences diminished when adjusting for covariates. Filipino and other Asians had greater odds of lifetime psychotic experiences when compared with Chinese, though again, differences diminished when adjusting for covariates. Among Black Americans, there were no significant ethnic subgroup differences.

CONCLUSION

Ethno-racial differences extend across the psychosis continuum. There are nuanced health profiles across and within ethno-racial categories. Differences may be attributable to differences in experiences living in the US, underscoring the need for community-specific interventions.

Child maltreatment, migration and risk of first-episode psychosis: results from the multinational EU-GEI study

BACKGROUND

Child maltreatment (CM) and migrant status are independently associated with psychosis. We examined prevalence of CM by migrant status and tested whether migrant status moderated the association between CM and first-episode psychosis (FEP). We further explored whether differences in CM exposure contributed to variations in the incidence rates of FEP by migrant status.

METHODS

We included FEP patients aged 18-64 years in 14 European sites and recruited controls representative of the local populations. Migrant status was operationalized according to generation (first/further) and region of origin (Western/non-Western countries). The reference population was composed by individuals of host country's ethnicity. CM was assessed with Childhood Trauma Questionnaire. Prevalence ratios of CM were estimated using Poisson regression. We examined the moderation effect of migrant status on the odds of FEP by CM fitting adjusted logistic regressions with interaction terms. Finally, we calculated the population attributable fractions (PAFs) for CM by migrant status.

RESULTS

We examined 849 FEP cases and 1142 controls. CM prevalence was higher among migrants, their descendants and migrants of non-Western heritage. Migrant status, classified by generation (likelihood test ratio:χ2 = 11.3, p = 0.004) or by region of origin (likelihood test ratio:χ2 = 11.4, p = 0.003), attenuated the association between CM and FEP. PAFs for CM were higher among all migrant groups compared with the reference populations.

CONCLUSIONS

The higher exposure to CM, despite a smaller effect on the odds of FEP, accounted for a greater proportion of incident FEP cases among migrants. Policies aimed at reducing CM should consider the increased vulnerability of specific subpopulations.

Migration history and risk of psychosis: results from the multinational EU-GEI study

BACKGROUND

Psychosis rates are higher among some migrant groups. We hypothesized that psychosis in migrants is associated with cumulative social disadvantage during different phases of migration.

METHODS

We used data from the EUropean Network of National Schizophrenia Networks studying Gene-Environment Interactions (EU-GEI) case-control study. We defined a set of three indicators of social disadvantage for each phase: pre-migration, migration and post-migration. We examined whether social disadvantage in the pre- and post-migration phases, migration adversities, and mismatch between achievements and expectations differed between first-generation migrants with first-episode psychosis and healthy first-generation migrants, and tested whether this accounted for differences in odds of psychosis in multivariable logistic regression models.

RESULTS

In total, 249 cases and 219 controls were assessed. Pre-migration (OR 1.61, 95% CI 1.06-2.44, p = 0.027) and post-migration social disadvantages (OR 1.89, 95% CI 1.02-3.51, p = 0.044), along with expectations/achievements mismatch (OR 1.14, 95% CI 1.03-1.26, p = 0.014) were all significantly associated with psychosis. Migration adversities (OR 1.18, 95% CI 0.672-2.06, p = 0.568) were not significantly related to the outcome. Finally, we found a dose-response effect between the number of adversities across all phases and odds of psychosis (⩾6: OR 14.09, 95% CI 2.06-96.47, p = 0.007).

CONCLUSIONS

The cumulative effect of social disadvantages before, during and after migration was associated with increased odds of psychosis in migrants, independently of ethnicity or length of stay in the country of arrival. Public health initiatives that address the social disadvantages that many migrants face during the whole migration process and post-migration psychological support may reduce the excess of psychosis in migrants.

An Intersectional Approach to Ethnoracial Disparities in Pathways to Care Among Individuals With Psychosis in Coordinated Specialty Care

Importance

Intersecting factors of social position including ethnoracial background may provide meaningful ways to understand disparities in pathways to care for people with a first episode of psychosis.

Objective

To examine differences in pathways to care by ethnoracial groups and by empirically derived clusters combining multiple factors of social and clinical context in an ethnoracially diverse multisite early-intervention service program for first-episode psychosis.

Design, Setting, and Participants

This cohort study used data collected on individuals with recent-onset psychosis (<2 years) by clinicians with standardized forms from October 2013 to January 2020 from a network of 21 coordinated specialty care (CSC) programs in New York State providing recovery-oriented, evidence-based psychosocial interventions and medications to young people experiencing early psychosis.

Exposures

Ethnoracial group and other factors of social position (eg, insurance status, living situation, English fluency, geographic region) intersecting with first-contact experiences (ie, type of first service, referral source, and symptoms at referral).

Main Outcomes and Measures

Outcome measures were time from onset to first contact, first contact to CSC, and onset to CSC.

Results

The total study sample consists of 1726 individuals aged 16 to 30 years and included 452 women (26%), 1263 men (73%), and 11 (<1%) with another gender enrolled in the network of CSC programs. The total sample consisted of 153 Asian (9%), 599 Black (35%), 454 Latinx (26%), and 417 White individuals (24%). White individuals had a significantly shorter time from onset to first contact (median [IQR], 17 [0-80] days) than Asian (median [IQR], 34 [7-94] days) and Black (median [IQR], 30 [1-108] days) individuals but had the longest period from first contact to CSC (median [IQR], 102.5 [45-258] days). Five distinct clusters of individuals emerged that cut across ethnoracial groups. The more disadvantaged clusters in terms of both social position and first-contact experiences had the longest time from onset to first contact, which were longer than for any single ethnoracial group.

Conclusions and Relevance

In this cohort study of individuals with recent-onset psychosis, time-to-treatment outcomes differed by ethnoracial group and by empirically derived clusters combining multiple factors of social and clinical context. The examination of disparities in durations to treatment through an intersectional, ethnoracial lens may improve understanding of the inequities resulting from the various intersecting factors that may compound delays in treatment initiation.

Global mental health research and practice: a decolonial approach

The global health movement is having a paradigm crisis-a period characterised by a questioning of one's values, goals, and sense of identity. Despite important advances in population health worldwide, global health and global mental health often produce and reproduce power imbalances and patterns of oppression and exploitation that perpetuate the current modern world system (ie, Eurocentric, capitalist, and patriarchal) and its entangled global hierarchies (eg, gender, economic, epistemic, and linguistic). A consensus is emerging to decolonise global mental health, but it is not clear how to move from rhetoric to action. In this Personal View, we aim to share our experiences and the practices developed in the context of the COVID-19 health care workers (HEROES) Study. To do so, we present our HEROES decolonial team approach, which comprises three underlying principles: epistemic justice, pragmatic solidarity, and sovereign acts. We have developed decolonial team practices such as co-creating communication spaces to foster horizontal and equitable dialogue, locating and managing the study database in Chile, and ensuring local teams' rights and access to the data without barriers.

The Association Between Exposure to COVID-19 and Mental Health Outcomes Among Healthcare Workers

Due to the unprecedented impact of the COVID-19 pandemic on health care systems, there has been great interest in the mental wellbeing of healthcare workers. While most studies investigated mental health outcomes among frontline vs. non-frontline healthcare workers, little is known about the impact of various work-related variables. The present study aimed to examine the association between work-related [i.e., having contact with COVID-19 patients, being redeployed due to the pandemic and availability of sufficient personal protective equipment (PPE)] and subjective (i.e., worries about getting infected or infecting others) exposures and self-reported mental health outcomes (i.e., psychological distress, depressive symptoms, and posttraumatic stress symptoms). Between February and May 2021, 994 healthcare workers employed at a variety of healthcare settings in the Netherlands filled out an online survey as part of the COVID-19 HEalth caRe wOrkErS (HEROES) study. Mental health outcomes were measured using the General Health Questionnaire-12, the Patient Health Questionnaire-9, and the Primary Care PTSD Screen for DSM-5. Approximately 13% reported depressive symptoms, 37% experienced psychological distress, and 20% reported posttraumatic stress symptoms. Multilevel linear models consisted of three levels: individual (work-related and subjective exposures), healthcare center (aggregated redeployment and availability of sufficient PPE), and regional (cumulative COVID-19 infection and death rates). Worries about infection were associated with all three mental health outcomes, whereas insufficient PPE was associated with psychological distress and depressive symptoms. There were no differences in outcomes between healthcare centers or provinces with different COVID-19 infection and death rates. Our findings highlight the importance of adequate PPE provision and the subjective experience of the COVID-19 pandemic. These factors should be part of interventions aimed at mitigating adverse mental health outcomes among healthcare workers during the COVID-19 pandemic.

COVID-19 Pandemic Factors and Depressive Symptoms Among Primary Care Workers in São Paulo, Brazil, October and November 2020

Objectives. To investigate associations between COVID-19-related factors and depressive symptoms among primary care workers (PCWs) in São Paulo, Brazil, and to compare the prevalence of probable depression among PCWs before and during the pandemic. Methods. In a random sample of primary care clinics, we examined 6 pandemic-related factors among 828 PCWs. We used multivariate Poisson regression with robust variance to estimate prevalence ratios for probable depression. We assessed the prevalence of probable depression in PCWs before and during the pandemic in 2 comparable studies. Results. Adjusted prevalence ratios were substantial for insufficient personal protective equipment; experiences of discrimination, violence, or harassment; and lack of family support. Comparisons between PCWs before and during the pandemic showed that the prevalence of probable depression among physicians, nurses, and nursing assistants was higher during the pandemic and that the prevalence among community health workers was higher before the pandemic. Conclusions. Our findings indicate domains that may be crucial to mitigating depression among PCWs but that, with the exception of personal protective equipment, have not previously been examined in this population. It is crucial that governments and communities address discriminatory behaviors against PCWs, promote their well-being at work, and foster family support. (Am J Public Health. 2022;112(5):786-794. https://doi.org/10.2105/AJPH.2022.306723).

The incidence of psychotic disorders among migrants and minority ethnic groups in Europe: findings from the multinational EU-GEI study

BACKGROUND

In Europe, the incidence of psychotic disorder is high in certain migrant and minority ethnic groups (hence: 'minorities'). However, it is unknown how the incidence pattern for these groups varies within this continent. Our objective was to compare, across sites in France, Italy, Spain, the UK and the Netherlands, the incidence rates for minorities and the incidence rate ratios (IRRs, minorities v. the local reference population).

METHODS

The European Network of National Schizophrenia Networks Studying Gene-Environment Interactions (EU-GEI) study was conducted between 2010 and 2015. We analyzed data on incident cases of non-organic psychosis (International Classification of Diseases, 10th edition, codes F20-F33) from 13 sites.

RESULTS

The standardized incidence rates for minorities, combined into one category, varied from 12.2 in Valencia to 82.5 per 100 000 in Paris. These rates were generally high at sites with high rates for the reference population, and low at sites with low rates for the reference population. IRRs for minorities (combined into one category) varied from 0.70 (95% CI 0.32-1.53) in Valencia to 2.47 (95% CI 1.66-3.69) in Paris (test for interaction: p = 0.031). At most sites, IRRs were higher for persons from non-Western countries than for those from Western countries, with the highest IRRs for individuals from sub-Saharan Africa (adjusted IRR = 3.23, 95% CI 2.66-3.93).

CONCLUSIONS

Incidence rates vary by region of origin, region of destination and their combination. This suggests that they are strongly influenced by the social context.

Facial Emotion Recognition in Psychosis and Associations With Polygenic Risk for Schizophrenia: Findings From the Multi-Center EU-GEI Case-Control Study

BACKGROUND AND HYPOTHESIS

Facial Emotion Recognition is a key domain of social cognition associated with psychotic disorders as a candidate intermediate phenotype. In this study, we set out to investigate global and specific facial emotion recognition deficits in first-episode psychosis, and whether polygenic liability to psychotic disorders is associated with facial emotion recognition.

STUDY DESIGN

828 First Episode Psychosis (FEP) patients and 1308 population-based controls completed assessments of the Degraded Facial Affect Recognition Task (DFAR) and a subsample of 524 FEP and 899 controls provided blood or saliva samples from which we extracted DNA, performed genotyping and computed polygenic risk scores for schizophrenia (SZ), bipolar disorder (BD), and major depressive disorder (MD).

STUDY RESULTS

A worse ability to globally recognize facial emotion expressions was found in patients compared with controls [B= -1.5 (0.6), 95% CI -2.7 to -0.3], with evidence for stronger effects on negative emotions (fear [B = -3.3 (1.1), 95% CI -5.3 to -1.2] and anger [B = -2.3 (1.1), 95% CI -4.6 to -0.1]) than on happiness [B = 0.3 (0.7), 95% CI -1 to 1.7]. Pooling all participants, and controlling for confounds including case/control status, facial anger recognition was associated significantly with Schizophrenia Polygenic Risk Score (SZ PRS) [B = -3.5 (1.7), 95% CI -6.9 to -0.2].

CONCLUSIONS

Psychosis is associated with impaired recognition of fear and anger, and higher SZ PRS is associated with worse facial anger recognition. Our findings provide evidence that facial emotion recognition of anger might play a role as an intermediate phenotype for psychosis.

Differential trajectories of tobacco smoking in people at ultra-high risk for psychosis: Associations with clinical outcomes

OBJECTIVE

People at ultra-high risk (UHR) for psychosis have a high prevalence of tobacco smoking, and rates are even higher among the subgroup that later develop a psychotic disorder. However, the longitudinal relationship between the course of tobacco smoking and clinical outcomes in UHR subjects is unknown.

METHODS

We investigated associations between tobacco smoking and clinical outcomes in a prospective study of UHR individuals (n = 324). Latent class mixed model analyses were used to identify trajectories of smoking severity. Mixed effects models were applied to investigate associations between smoking trajectory class and the course of attenuated psychotic symptoms (APS) and affective symptoms, as assessed using the CAARMS.

RESULTS

We identified four different classes of smoking trajectory: (i) Persistently High (n = 110), (ii) Decreasing (n = 29), (iii) Persistently Low (n = 165) and (iv) Increasing (n = 20). At two-year follow-up, there had been a greater increase in APS in the Persistently High class than for both the Persistently Low (ES = 9.77, SE = 4.87, p = 0.046) and Decreasing (ES = 18.18, SE = 7.61, p = 0.018) classes. There were no differences between smoking classes in the incidence of psychosis. There was a greater reduction in the severity of emotional disturbance and general symptoms in the Decreasing class than in the High (ES = -10.40, SE = 3.41, p = 0.003; ES = -22.36, SE = 10.07, p = 0.027), Increasing (ES = -11.35, SE = 4.55, p = 0.014; ES = -25.58, SE = 13.17, p = 0.050) and Low (ES = -11.38, SE = 3.29, p = 0.001; ES = -27.55, SE = 9.78, p = 0.005) classes, respectively.

CONCLUSIONS

These findings suggests that in UHR subjects persistent tobacco smoking is associated with an unfavorable course of psychotic symptoms, whereas decrease in the number of cigarettes smoked is associated with improvement in affective symptoms. Future research into smoking cessation interventions in the early stages of psychoses is required to shine light on the potential of modifying smoking behavior and its relation to clinical outcomes.

The impact of the COVID-19 pandemic on the mental health of healthcare workers: study protocol for the COVID-19 HEalth caRe wOrkErS (HEROES) study

BACKGROUND

Preliminary country-specific reports suggest that the COVID-19 pandemic has a negative impact on the mental health of the healthcare workforce. In this paper, we summarize the protocol of the COVID-19 HEalth caRe wOrkErS (HEROES) study, an ongoing, global initiative, aimed to describe and track longitudinal trajectories of mental health symptoms and disorders among health care workers at different phases of the pandemic across a wide range of countries in Latin America, Europe, Africa, Middle-East, and Asia.

METHODS

Participants from various settings, including primary care clinics, hospitals, nursing homes, and mental health facilities, are being enrolled. In 26 countries, we are using a similar study design with harmonized measures to capture data on COVID-19 related exposures and variables of interest during two years of follow-up. Exposures include potential stressors related to working in healthcare during the COVID-19 pandemic, as well as sociodemographic and clinical factors. Primary outcomes of interest include mental health variables such as psychological distress, depressive symptoms, and posttraumatic stress disorders. Other domains of interest include potentially mediating or moderating influences such as workplace conditions, trust in the government, and the country's income level.

RESULTS

As of August 2021, ~ 34,000 health workers have been recruited. A general characterization of the recruited samples by sociodemographic and workplace variables is presented. Most participating countries have identified several health facilities where they can identify denominators and attain acceptable response rates. Of the 26 countries, 22 are collecting data and 2 plan to start shortly.

CONCLUSIONS

This is one of the most extensive global studies on the mental health of healthcare workers during the COVID-19 pandemic, including a variety of countries with diverse economic realities and different levels of severity of pandemic and management. Moreover, unlike most previous studies, we included workers (clinical and non-clinical staff) in a wide range of settings.

Predictors of Persistent Symptoms in People in Coordinated Specialty Care Services for Early Psychosis in New York State

OBJECTIVE

This study aimed to determine the prevalence and predictors of persistent transdiagnostic symptoms in the first year of enrollment in OnTrackNY, a coordinated specialty care (CSC) program for individuals with recent-onset nonaffective psychosis.

METHODS

Three groups were defined by using the Mental Illness Research, Education, and Clinical Centers Global Assessment of Functioning symptom subscale: persistently symptomatic, intermittent, and improving to moderate. The authors compared groups on baseline demographic characteristics, family and living situation, clinical measures, and pathways to care.

RESULTS

Of 1,129 eligible participants, 12% were persistently symptomatic through follow-up. Being medication nonadherent, being homeless, having a diagnosis of schizophrenia, and having a longer duration between symptom onset and program enrollment were predictive of persistent symptoms during the first year of CSC.

CONCLUSIONS

Findings suggest that despite intensive treatment, severe symptoms in young people with psychosis may persist because of economic barriers, treatment delays, and lack of stability.

Sociodemographic, clinical and help-seeking characteristics of homeless young people with recent onset of psychosis enrolled in specialized early intervention services

AIM

To examine differences in demographic, clinical, social, functional and help-seeking characteristics of homeless vs housed individuals enrolled in specialized early intervention teams in the United States.

METHODS

Participants comprised 1349 individuals enrolled across 21 teams. Teams report individual-level data including homelessness status at admission. Bivariate differences between homeless and housed participants were analysed using Wilcoxon-rank, chi-square, Fisher-exact and t tests, as appropriate.

RESULTS

Approximately 5% of participants were homeless at admission. Homeless participants were less likely to be enrolled in school and/or employed (12.2% vs 43.4%); to have more involvement in the legal system (23.0% vs 6.2%); and to have had a more restrictive pathway to care, than housed participants.

CONCLUSIONS

Homeless young people with recent-onset psychosis have a substantially greater need for a diversity of services for psychosocial needs. Homeless individuals may also have a more adverse pathway to care and directed outreach to engage this population may be needed.

Cognitive functioning throughout adulthood and illness stages in individuals with psychotic disorders and their unaffected siblings

Important questions remain about the profile of cognitive impairment in psychotic disorders across adulthood and illness stages. The age-associated profile of familial impairments also remains unclear, as well as the effect of factors, such as symptoms, functioning, and medication. Using cross-sectional data from the EU-GEI and GROUP studies, comprising 8455 participants aged 18 to 65, we examined cognitive functioning across adulthood in patients with psychotic disorders (n = 2883), and their unaffected siblings (n = 2271), compared to controls (n = 3301). An abbreviated WAIS-III measured verbal knowledge, working memory, visuospatial processing, processing speed, and IQ. Patients showed medium to large deficits across all functions (ES range = -0.45 to -0.73, p < 0.001), while siblings showed small deficits on IQ, verbal knowledge, and working memory (ES = -0.14 to -0.33, p < 0.001). Magnitude of impairment was not associated with participant age, such that the size of impairment in older and younger patients did not significantly differ. However, first-episode patients performed worse than prodromal patients (ES range = -0.88 to -0.60, p < 0.001). Adjusting for cannabis use, symptom severity, and global functioning attenuated impairments in siblings, while deficits in patients remained statistically significant, albeit reduced by half (ES range = -0.13 to -0.38, p < 0.01). Antipsychotic medication also accounted for around half of the impairment in patients (ES range = -0.21 to -0.43, p < 0.01). Deficits in verbal knowledge, and working memory may specifically index familial, i.e., shared genetic and/or shared environmental, liability for psychotic disorders. Nevertheless, potentially modifiable illness-related factors account for a significant portion of the cognitive impairment in psychotic disorders.

Social disadvantage, linguistic distance, ethnic minority status and first-episode psychosis: results from the EU-GEI case-control study

BACKGROUND

Ethnic minority groups in Western countries face an increased risk of psychotic disorders. Causes of this long-standing public health inequality remain poorly understood. We investigated whether social disadvantage, linguistic distance and discrimination contributed to these patterns.

METHODS

We used case-control data from the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study, carried out in 16 centres in six countries. We recruited 1130 cases and 1497 population-based controls. Our main outcome measure was first-episode ICD-10 psychotic disorder (F20-F33), and exposures were ethnicity (white majority, black, mixed, Asian, North-African, white minority and other), generational status, social disadvantage, linguistic distance and discrimination. Age, sex, paternal age, cannabis use, childhood trauma and parental history of psychosis were included as a priori confounders. Exposures and confounders were added sequentially to multivariable logistic models, following multiple imputation for missing data.

RESULTS

Participants from any ethnic minority background had crude excess odds of psychosis [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.69-2.43], which remained after adjustment for confounders (OR 1.61, 95% CI 1.31-1.98). This was progressively attenuated following further adjustment for social disadvantage (OR 1.52, 95% CI 1.22-1.89) and linguistic distance (OR 1.22, 95% CI 0.95-1.57), a pattern mirrored in several specific ethnic groups. Linguistic distance and social disadvantage had stronger effects for first- and later-generation groups, respectively.

CONCLUSION

Social disadvantage and linguistic distance, two potential markers of sociocultural exclusion, were associated with increased odds of psychotic disorder, and adjusting for these led to equivocal risk between several ethnic minority groups and the white majority.

From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States

The authors examine U.S.-based evidence that connects characteristics of the social environment with outcomes across the psychosis continuum, from psychotic experiences to schizophrenia. The notion that inequitable social and economic systems of society significantly influence psychosis risk through proxies, such as racial minority and immigrant statuses, has been studied more extensively in European countries. While there are existing international reviews of social determinants of psychosis, none to the authors' knowledge focus on factors in the U.S. context specifically-an omission that leaves domestic treatment development and prevention efforts incomplete and underinformed. In this review, the authors first describe how a legacy of structural racism in the United States has shaped the social gradient, highlighting consequential racial inequities in environmental conditions. The authors offer a hypothesized model linking structural racism with psychosis risk through interwoven intermediary factors based on existing theoretical models and a review of the literature. Neighborhood factors, cumulative trauma and stress, and prenatal and perinatal complications were three key areas selected for review because they reflect social and environmental conditions that may affect psychosis risk through a common pathway shaped by structural racism. The authors describe evidence showing that Black and Latino people in the United States suffer disproportionately from risk factors within these three key areas, in large part as a result of racial discrimination and social disadvantage. This broad focus on individual and community factors is intended to provide a consolidated space to review this growing body of research and to guide continued inquiries into social determinants of psychosis in U.S. contexts.

Disengagement From Early Intervention Services for Psychosis: A Systematic Review

OBJECTIVE

Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings.

METHODS

A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality.

RESULTS

Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement.

CONCLUSIONS

Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.

Predictors of Early Discharge From Early Intervention Services for Psychosis in New York State

OBJECTIVE

Although specialized early intervention services (EISs) for psychosis promote engagement in care, a substantial number of individuals who receive these services are discharged from care earlier than expected. The main goal of this study was to examine predictors of early discharge in a large sample of individuals enrolled in an EIS program in the United States.

METHODS

This cohort study (N=1,349) used programmatic data from OnTrackNY, an EIS program that delivers evidence-based interventions to youths across New York State experiencing a first episode of nonaffective psychosis. The main outcome was "early discharge," which was operationalized as discharge prior to completing 12 months of treatment. Cox proportional hazard regression models were used to assess the association between sociodemographic, clinical, and support system predictors and early discharge.

RESULTS

The estimated probability of discharge before 1 year was 32%. Participants who at baseline had poor medication adherence, had no health insurance, were living alone or with nonparental family, or were using cannabis were at higher risk of leaving services within the first 12 months after enrollment. Individuals with higher social functioning were at lower risk of being discharged early from OnTrackNY, but those with higher occupational functioning were at a higher risk.

CONCLUSIONS

Predictors of early discharge from EISs largely overlapped with previously identified predictors of poor prognosis in early psychosis. However, the association between early discharge and high occupational functioning indicates that trajectories leading up to discharge are heterogeneous.

Trajectories of occupational and social functioning in people with recent-onset non-affective psychosis enrolled in specialized early intervention services across New York state

BACKGROUND

Despite the benefits of early intervention services for the initial stages of psychosis ongoing impairments in functioning are common.

AIMS

To identify 1-year trajectories of occupational and social functioning in individuals enrolled in OnTrackNY, a statewide program offering early intervention services for recent-onset psychosis in community settings.

METHOD

We included 937 persons with recent-onset psychosis enrolled at 19 programs across New York State. Demographic, social and clinical data was collected at program entry and at 3, 6, 9 and 12 months. We used growth mixture models to identify occupational and social functioning trajectories and examined the association between trajectory class, baseline factors and symptoms during 1-year follow-up.

RESULTS

Four distinct trajectory classes of occupational and social functioning were identified. The converging (58.0%) class had disparate levels of functioning at baseline (low occupational, higher social) which eventually converged. The other classes had high-stable (14.8%), moderate-stable (17.8%) and low-improving (9.4%) trajectories. Female gender, educational attainment and private insurance status were significantly associated with the trajectory characterized by higher functioning, while living alone, homelessness, a longer period from psychosis onset to program enrollment, a schizophrenia diagnosis and cannabis use at enrollment were associated with the poorest trajectory. The differences in severity of symptoms by trajectory class diminished over time.

CONCLUSIONS

Trajectories of occupational and social functioning showed substantial variation, but overall, remained stable or improved during 1-year follow-up. The relationship between symptoms and occupational and social functioning attenuated after the acute treatment phase.

Racial-Ethnic Differences in Service Use Patterns Among Young, Commercially Insured Individuals With Recent-Onset Psychosis

OBJECTIVE

The aim of this study was to investigate racial-ethnic differences in use of mental health services and antipsychotic medication in the year following the recent onset of a psychotic disorder and to examine the role of household income as a proxy for socioeconomic status.

METHODS

Deidentified administrative claims data from the OptumLabs Data Warehouse were used to identify 8,021 commercially insured individuals ages 14 through 30 with a recent-onset psychotic disorder (January 1, 2011, through December 31, 2015). The authors compared mental health service use among African-American (11.5%), Hispanic (11.0%), and non-Hispanic white (77.4%) individuals during the year following an index diagnosis and adjusted these analyses for household income.

RESULTS

The probability of any use of outpatient mental health services was lower among African-American (67.4%±1.4%) and Hispanic individuals (66.5%±1.5%) compared with non-Hispanic white patients (72.3%±0.6%; p<0.05 for each comparison). Among those who used services, African-American and Hispanic individuals had fewer mean outpatient mental health visits per year compared with non-Hispanic whites (9.7±0.7 and 10.2±0.7 versus 14.3±0.5, respectively, p<0.001 for each comparison). These racial-ethnic differences in service use remained after adjustment for household income.

CONCLUSIONS

Among young, commercially insured individuals using outpatient services following an index diagnosis of psychotic disorder, African Americans and Hispanics received less intensive outpatient mental health care than their non-Hispanic white counterparts. Amid the upsurge of early intervention programs, special attention should be paid to increasing access to mental health services for racial-ethnic minority groups.

Service Use Following First-Episode Schizophrenia Among Commercially Insured Youth

OBJECTIVE

To investigate patterns of mental health service and antipsychotic use following a first-episode schizophrenia (FES) and to examine the role of the treatment setting in which individuals are first diagnosed.

METHOD

Analysis of de-identified administrative claims data from the OptumLabs Data Warehouse was used to identify 1450 privately insured youth and young adults aged 14 through 30 with FES from January 1, 2011 through December 31, 2015. Regression analysis was used to estimate the use of mental health services during the year following FES, by type of service and by site of index diagnosis.

RESULTS

In the year following FES, 79.7% of youth received outpatient mental health services and 35.8% filled a prescription for antipsychotic medication. Among service users, mean outpatient visits were 15.9 and mean antipsychotic fills were 8.3. Youth who received an index diagnosis of FES in an inpatient setting were more likely to fill an antipsychotic medication than youth with FES in other settings. Youth who received an index diagnosis of FES during a specialty mental health outpatient visit had greater use of outpatient mental health than youth who received their diagnosis during a primary care visit.

CONCLUSIONS

Despite evidence-based guidelines supporting outpatient psychosocial care and antipsychotic treatment for FES, one-fifth of this cohort did not use outpatient services and the majority did not fill any prescriptions for antipsychotic medications during the year following FES. Our findings provide renewed urgency to ongoing efforts to accelerate early identification and care coordination for youth with FES.

Migration and psychosis: a meta-analysis of incidence studies

BACKGROUND

The aims of this meta-analysis are (i) to estimate the pooled relative risk (RR) of developing non-affective psychotic disorder (NAPD) and affective psychotic disorder (APD) among migrants and their children; (ii) to adjust these results for socioeconomic status (SES); (iii) to examine the sources of heterogeneity that underlie the risk of NAPD.

METHODS

We included population-based incidence studies that reported an age-adjusted RR with 95% confidence interval (CI) published 1 January 1977-12 October 2017 and used a random-effects model.

RESULTS

We retrieved studies performed in Europe (n = 43), Israel (n = 3), Canada (n = 2) and Australia (n = 1). The meta-analysis yielded a RR, adjusted for age and sex, of 2.13 (95% CI 1.99-2.27) for NAPD and 2.94 (95% CI 2.28-3.79) for APD. The RRs diminished, but persisted after adjustment for SES. With reference to NAPD: a personal or parental history of migration to Europe from countries outside Europe was associated with a higher RR (RR = 2.94, 95% CI 2.63-3.29) than migration within Europe (RR = 1.88, 95% 1.62-2.18). The corresponding RR was lower in Israel (RR = 1.22; 0.99-1.50) and Canada (RR = 1.21; 0.85-1.74). The RR was highest among individuals with a black skin colour (RR = 4.19, 95% CI 3.42-5.14). The evidence of a difference in risk between first and second generation was insufficient.

CONCLUSIONS

Positive selection may explain the low risk in Canada, while the change from exclusion to inclusion may do the same in Israel. Given the high risks among migrants from developing countries in Europe, social exclusion may have a pathogenic role.

Diagnostic value of a simplified screening test for metabolic syndrome in a Dutch patient cohort with schizophrenia spectrum disorders

OBJECTIVE:

The aim of this study was to establish the specificity and sensitivity of a simplified screening test based on diastolic blood pressure and waist circumference for predicting metabolic syndrome.

METHOD:

Demographic, anthropometric (waist circumference and systolic and diastolic blood pressure) and laboratory (triglyceride, high-density lipoprotein and fasting glucose) data were collected from a large cohort of Dutch patients with a schizophrenia spectrum disorder in order to determine whether patients fulfilled the Western criteria of the International Diabetes Federation (IDF) for metabolic syndrome. The sensitivity, specificity, likelihood ratio of a positive or negative test outcome and positive and negative predictive values of the simplified test (only waist circumference and diastolic blood pressure) were calculated.

RESULTS:

Of 252 recruited patients, 55% met the IDF criteria for metabolic syndrome. The sensitivity and the specificity of the simplified test were 65% and 85%, respectively. The likelihood ratios of positive and negative test outcomes were 4.35 and 0.41, respectively, and the positive and negative predictive values were 87% and 67%, respectively.

CONCLUSION:

This simplified screening test did not have diagnostic validity for metabolic syndrome in a Dutch cohort of patients with schizophrenia spectrum disorder.